Just culture

1. Just culture Jane Barnsteiner, PhD, RN, FAAN Joanne Disch, PhD, RN, FAAN

2. High Reliability Organizations (HRO) Safety is dependent upon health care systems and organizations, Patients should be safe from injury caused by interactions with the systems and organizations of care.

3. High Reliability Organizations (HRO) HRO Organizations that have cultures of safety, • Foster a learning environment • Evidence-based care • Positive working environments • Committed to improving the safety and quality of care • Transparency

4. High Reliability Organizations (HRO):Characteristics Characteristics of HROs include: • safety and quality-centered culture • direct involvement of top and middle leadership • safety and quality efforts aligned with the strategic plan • established infrastructure for safety and continuous improvement • active engagement of staff across the organization

5. Just Culture • Within a culture of safety, when an adverse event occurs, the focus is on what went wrong, not who is the problem.

6. Evolutionary Approaches • Shame and Blame • System Errors • Just Culture

7. Culture of Blame A culture of blame has been pervasive in healthcare. The focus has often been to try to determine who has been at fault and, all too often, to mete out discipline. • leads to hiding rather than reporting errors and is the antithesis of a culture of safety.

8. Blame and Shame • Expectation of perfection • Finger pointing • Identify who did it rather than what happened • Defensiveness • Fear of • legal liability • loss of credibility and reputation • Punishment • Secrecy and cover up

9. Blameless Reporting System • Confidential reporting • Voluntary and anonymous • Transparency of errors and latent conditions • Event analysis • Guard against blame, attribution and hindsight bias • Improvements identified with system of feedback • Disclosure and truth telling

10. Blameless Reporting System In a blameless reporting system, the question is not Who did it? But … • What happened? • Has it happened before? • Could it happen again? • What caused it to happen? • Who should be told?

11. Managing Healthcare Risk – The Three Behaviors At-Risk Behavior Reckless Behavior Normal Error Intentional Risk-Taking Unintentional Risk-Taking Product of our current system design • Manage through: • Understanding our at-risk behaviors • Removing incentives for at-risk behaviors • Creating incentives for healthy behavior • Increasing situational awareness • Manage through: • Disciplinary action • Manage through changes in: • Processes • Procedures • Training • Design • Environment Normal Error Negligence? Recklessness *David Marx – Just Culture

12. These principles apply to all health care organizations • Hospitals • Clinics • Schools of nursing

13. Reporting Systems in School of Nursing • What is the process when an error takes place with a student? • How is the situation analyzed? • What is the reporting process? • What if anything is entered into the student file? • What is the debriefing process with the student? • How are errors used as teachable moments with other students, if at all? • With other faculty, if at all?

14. In conclusion To improve the quality and safety of health care, we must create environments within which people can report errors, near-misses and hazardous situations without fear of retaliation, blame, or unwarranted discipline. Most errors and near-misses are a result of system malfunctions. If individuals act in negligent, risky or reckless behavior, there should be consequences. A just culture requires system accountability and individual responsibility.